Provider Demographics
NPI:1164045035
Name:PERALTA, MARIANA S
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:S
Last Name:PERALTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 MORRISTOWN RD
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-1654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131 MORRISTOWN RD
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-1654
Practice Address - Country:US
Practice Address - Phone:877-441-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00998001101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00998001OtherSTATE LICENSE